| NPI | 1295011492 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: TX AT2219) |
| Additional Taxonomies | 221700000X Art Therapist |
| 225700000X Massage Therapist (Licence: TX MT101180) | |
| Enumeration Date | 2011-11-01 |
| Last Update Date | 2011-11-01 |